Carson, Charles Form-VS No.61. 1-20-30-75,000(17-4362)
NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
OW—This Permit can be signed only by the Local trar(De tty or Su��'strar)of the
tion District own,V ill or City)in which the dee occurred after the FILING and accsptan et a CDR*
RECT AND (Town,
PJ.ETE CERTIFICATE OF DEATH, ',IBLY WRITTEN IN DURABLE BLACK INK.
Dist No.. _ • = R ed No.
Cozen arrtiri U -- _ 9✓!
-Town, il- 1{ O�(ideals Ua3llS ,�Date of� .. 1
loge,or City" ~� Se�_! 1.. Age...1.. rs. Color
(If city,give street ad , -
(�Zros.)
Cause of Death ,��_2f/✓---- ---ry_ _----- —_
Place of B ' or Remo : .A.2. .-!c..
'drCem _: _ __ ._._ ' .�.� ----_Date of Burial 1 -_19�-)
Certificate of Death of —
.A - -__ -. •_____61124Z-ZO.Z.4.../...—.......
(Give full name of deceased)
having been presented to me containing the above stated particulars, and, after careful examination
the same appearing to be COMPLETE, CORRECT, AND SATISFACTORY AS REQUIRED BY
LAW have accepted the same er registration,have recorded it in my Local Record with
the ve stated Registered N 719.1 basis there I Y A P
(v v ng cbar8e ) (Inter. oth 'e up se of i the wp
Dated_ -- — 19 (Signed) - _- -
Local Registrar
This Permit is-aut for the Removal (and Interment or Cremation) of a body to any partof the
State (subject to local cemetery or other regulations),unless removal is by common carrier,in which case a
T....a*ak......n.tart H..es\i.r�..IYJ
ENDORSEMENT OF SEXTON OR PERSON IN
CHARGE OF PREMISES ON WHICH INTER-
MENTS OR �RECREEM-AATIONS ARE
Date of..____ _ _1,12 . -�T " ` _
( meat or crem on)
(Signed)--.. ._...._ _.._._._....
(Parson �'
is chatga�'�!v_...�!?At _.--._ .1
(Name of Cemetery, rematorium,etc.)
Person in charge must return this Permit to Registrar of his District within
SEVEN(7)DAYS from above date. If no person is in charge,the UNDER
TAXER MUST SIGN ABOVE STATEMENT,write across the face of the Permit
the words"No person in charge,"and FILE PERMIT WITHIN THREE(3)
DAYS with Registrar of District in which cemetery is located.
EXTRACTS OF THE VITAL STATISTICWLAW'
t; 379. Duties of undertaker. In each case the undertaker, or person
having charge of the corpse,shall file the certificate of death with the registrar
of the district in which the death occurred and obtain a'bu#.ial or removal
permit prior to any disposition of the body. * * * The "undertaker shall
deliver the burial permit-to the person in charge of the place' burial, before
interring or, disposing of the body; or shall attach the removal
peemit.:to the-box cop ain �n when.ahippe5l. and transportation
company; said permit to acedsupan the corpse to its estination, where if
within the state of New York,its be delivered to the person in charge
of the place of burial.
$389. Duties of undertakers; interment within the state. If the inter-
ment,or other disposition of the body is to be made within the state,the word-
ing.of the burial or removal permit may be limited,to a.statement by the
registrar,and over his signature that a satisfactory certificate of death,having
been filed with him,as required by law,permission is granted to inter,remove
or dispose otherwise of the body, stating the name, age,sex,cause.ofdeath,
and other necessary details upon the form prescribed by the commissioner of
health.
$ 381. Interments. No person in charge of any premises on which
interments or cremations are made shall inter or permit the inteiment other .
disposition of any body unless it is accompanied by a burial, ere or
transit permit,as herein provided. Such person shall endorse upon the •t,
the date of interment,or cremation over his signature,and shall return ell
permits so endorsed to the registrar of his district within ettren days front the
date of interment or cremation. He shall keep a record of all bodies interred
or otherwise disposed of on the premises under his charge,in each case stating
the name of each"dermied person,place of death, date of burial or disposal,
and name and address of the undertaker; which record shah st all times be
open to official inspection; provided that the undertaker orf person having
charge of the corpse, when burying a body in a cemetery or .burial ground
having no person in charge, shall sign the burial or removal permit,giving
the date of burial,and shall write across the face of the permit the words "No
person in charge,"and file the burial or removal permit within three days;with
the registrarof the district in which the cemetery is located. K.
NW"SEXTONS and UNDERTAKERS violating the law relative to the re-
turn of permits are liable to a penalty of NOT LESS THAN FIVE DOLLARS
NOR MORE THAN FIFTY DOLLARS FOR THE FIRST OFFENSE. The
loco will,be enforced. Local Registrars,are required,under penalty,to report